The SHARE Approach—Putting Shared Decisionmaking Into Practice: A User’s Guide for Clinical Teams
Cover Note: The SHARE Approach is a 1-day training program developed by the Agency for Healthcare Research and Quality (AHRQ) to help health care professionals work with patients to make the best possible health care decisions. It supports shared decisionmaking through the use of patient-centered outcomes research (PCOR).
Shared decisionmaking occurs when a health care provider and a patient work together to make a health care decision that is best for the patient. The optimal decision takes into account evidence-based information about available options, the provider's knowledge and experience, and the patient's values and preferences.
The SHARE Approach
Essential Steps of Shared Decisionmaking
Step 1: Seek your patient's participation.
This user's guide is designed to help you and your practice implement shared decisionmaking between clinicians and patients to improve health care for all. (Please note that references to patients in this guide also include caregivers and family members.)
Implementing shared decisionmaking in your practice encourages your patients to be more involved in their health care decisions. This may be different from "usual practice" that, according to numerous studies,1-4 does not always include asking patients their preferred role in the decisionmaking process, adjusting care to meet patients' preferences, or the use of evidence-based decision aids and other tools to support patient decisionmaking.
Inside This Guide
This guide highlights a number of "how to" strategies for starting, maintaining, and evaluating a shared decisionmaking program in clinical practice settings of all sizes. It is supplemented with numerous case examples from a number of organizations that have implemented shared decisionmaking in varied ways to improve the quality of care that they provide to their patients.
This guide also highlights and encourages the application of patient-centered outcomes research tools and decision support resources available from the Agency for Healthcare Research and Quality (AHRQ) and other organizations.
Information and suggestions in this guide are based on a growing body of research, literature, and interviews with health care experts who have implemented evidence-based shared decisionmaking..
Putting Shared Decisionmaking into Practice
Just like introducing any other innovation into practice, implementing shared decisionmaking requires leadership and a coordinated plan to make it work. Here are some of the key activities that a clinical practice should consider as part of the shared decisionmaking planning process. Each of these activities is described in the subsections that follow. Additional resources that you may find helpful are described at the end of this user's guide.
- Get leadership buy-in.
- Develop an implementation team.
- Select an approach that is tailored to your practice.
- Provide training and ongoing support to all staff.
- Start small, then take it to scale.
- Create a physical setting for shared decisionmaking.
- Create a library of evidence-based educational resources and decision aids.
- Streamline shared decisionmaking work processes into day-to-day operations.
- Evaluate the ongoing implementation of shared decisionmaking.
1. Get Leadership Buy-In
Obtaining the full commitment and support of practice leaders and administrators is critical to putting the pieces into place for the successful implementation of shared decisionmaking. This is the first step in changing the organizational culture to be more supportive of patient-centered care, including shared decisionmaking.
AHRQ's Achieving Patient-Centered Care with Shared Decisionmaking: A Brief for Administrators and Practice Leaders (Tool 9) contains information about shared decisionmaking and how adopting this patient-centered method can help practices meet the mandates of new patient-centered laws and programs. This tool should be shared and discussed with administrators who make the decisions in the practice. Deciding to implement shared decisionmaking and the use of evidence-based educational materials in the practice starts at the top of the administrative chain of command.
In addition to leadership buy-in, it also helps to have a shared decisionmaking champion on board—someone who is widely respected by other staff members, committed to the value of shared decisionmaking, and willing to engage others.
2. Develop a Shared Decisionmaking Implementation Team
Start your implementation by appointing a shared decisionmaking team. Having a team will engage staff who can help develop an approach that is appropriate for your clinical setting.
Potential members may include the following staff:
- Physician, physician assistant, or nurse practitioner.
- Health educator, decision coach, or nurse.
- Member of the administrative team.
- Member of the front desk staff.
- Other health care team members (e.g., pharmacist, psychologist).
Responsibilities of the shared decisionmaking team include:
- Developing a shared decisionmaking implementation plan.
- Identifying potential barriers to implementation and developing creative solutions.
- Developing a process for identifying eligible patients.
- Reviewing patient decision support materials, such as those available from AHRQ (see the Resources section at the end of this guide).
- Conducting trainings of clinicians and other team members.
- Choosing an approach for disseminating materials to patients.
- Monitoring the ongoing adoption of shared decisionmaking tools and practices.
|Involving Staff in Addition to Treating Clinicians—Examples|
|A program called CommonGround uses peer specialists to help mental health clients identify treatment preferences and effectively communicate them to clinicians.5|
|A telephonic care management program enables patients to participate in their treatment decisions by employing telephone–based health coaches (registered nurses, dietitians, respiratory therapists, and pharmacists) who help at-risk individuals learn to participate in decisions with their doctors.6|
3. Select an Approach that Is Tailored to Your Practice
The examples provided in this document show that shared decisionmaking can be implemented in many different ways. AHRQ's consumer research summaries and patient decision aids (see Decision Support Resources section), along with other evidence-based resources, can be used directly with patients by treating clinicians and other clinical support staff during patient encounters.
Some institutions hire health coaches or health educators to work closely with patients to outline their options about treatments. Other practices mail patients a decision aid or a written recommendation to review a patient decision aid available on a specific Web site prior to their office visit.
Think about what approach will work best for your practice, so you can plan your shared decisionmaking approach effectively. Share your plans with clinic staff and incorporate their feedback into your plan to maximize acceptance.
Address Time Concerns Proactively
Many clinicians don't understand that implementing a shared decisionmaking approach doesn't have to take more time. It's an understandable concern, since health care professionals already feel they have too little time with patients. In reality, with training, studies have found that clinicians can implement shared decisionmaking without increasing the length of the consultation time.10-12 AHRQ's shared decisionmaking tip (fact) sheets and scripts (see Decision Support Resources section) can help clinicians learn how to do this.
|Practices Implement Multiple Approaches—Examples|
|Dartmouth-Hitchcock Medical Center fully integrates shared decisionmaking into breast cancer care. The staff contact newly diagnosed breast cancer patients to provide information that will help them choose a course of treatment based on their own preferences and concerns. Patients receive a free video/DVD, booklet, and questionnaire to help prepare them for their initial surgeon visit; one-on-one counseling sessions with center staff are also available.7|
|The University of Kansas Medical Center placed interactive, culturally appropriate decision aids at kiosks during large community health fairs, and in safety net clinics to improve patient knowledge and use of smoking cessation resources.8|
|Group Health chose to emphasize preference-sensitive health conditions related to elective surgical procedures. They incorporated the use of decision aids for patients with hip and knee osteoarthritis, abnormal uterine bleeding, uterine fibroids, lumbar herniated disc, lumbar spinal stenosis, chronic stable angina, benign prostatic hyperplasia, early-stage prostate cancer, and early-stage breast cancer.9|
4. Provide Training to All Staff
Every staff member who interacts with patients needs to understand shared decisionmaking and his or her role in the shared decisionmaking process.
AHRQ provides accredited training on shared decisionmaking through its SHARE Approach workshop. This FREE, 1-day train-the-trainer workshop is designed to provide basic information on implementing shared decisionmaking in practice, specific communication skills, dialogue with patients, and how to find resources and educational materials to augment use of evidence-based practice with shared decisionmaking in real life clinic settings. The SHARE Approach workshop is offered multiple times a year across the country to train health professionals and practice leaders who in turn train others in their local health care settings and institutions.
AHRQ also provides supportive materials and a shared decisionmaking toolkit for use in training clinic staff (www.ahrq.gov/shareddecisionmaking).
Provide Ongoing Support
A one-time training—no matter how well executed—is insufficient to establish shared decisionmaking as an element of usual care in your practice. Clinicians who interact with patients in shared decisionmaking encounters need ongoing supportive training to fully integrate the use of appropriate evidence-based resources and shared decisionmaking into their regular practice.
Ongoing coaching can help clinicians master this new skill. Coaching strategies may include quick reviews immediately following a clinician-patient encounter or recording encounters for more detailed reviews at a later time.
AHRQ provides the following ongoing support activities for participants of the SHARE Approach workshop.
- SHARE Approach Learning Network: AHRQ supports a forum for trained participants to share their experiences, challenges, and lessons learned with integrating the SHARE Approach materials into their own practice, setting up their own training programs, and other topics of interest to them.
- SHARE Approach Web conferences: AHRQ conducts three accredited Web conferences a year to support trained workshop participants in implementing shared decisionmaking and AHRQ's evidence-based decision-support resources in practice.
|It can be hard to squeeze adequate training time into a clinician's busy day|
|In an interview with Shawn Mincer, M.S.W. (research coordinator in the Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Aug. 7, 2013), trainers met with surgeons for quick 5-minute reviews between patients.
You may find that regular staff meetings or scheduled in-service days also provide opportunities for more intensive trainings of 1 hour or more.
Continuing Education Activities
AHRQ's Effective Health Care (EHC) Program offers opportunities to earn continuing medical education/continuing education (CME/CE) credits for studying evidence about specific health conditions. FREE online modules on numerous clinical topics are available for physicians, physician assistants, pharmacists, nurses, nurse practitioners, medical assistants, health education specialists, and case managers. (https://effectivehealthcare.ahrq.gov/products-tools/education-resources)
5. Start Small, Then Take It to Scale
Begin your introduction of shared decisionmaking as a pilot program in one department where there is a strong interest in participating. Decide which clinical procedures and/or treatments your practice wants to focus on first, and gather resources specific to those procedures.
Starting small will allow you to test specific approaches and discover what works best for your practice. Once you have successfully integrated shared decisionmaking into one department (or for one health condition), begin introducing it to additional departments or for other health conditions, testing it carefully in each one before moving on. As staff become more comfortable with shared decisionmaking and begin to see its benefits, their successes will become your best advertisement for this approach in other departments.
6. Create a Physical Setting for Shared Decisionmaking
Depending on how your practice/institution decides to implement shared decisionmaking, you may need to address practical, logistical issues in your shared decisionmaking plan.
If your approach includes reviewing decision aids with patients or having them review such information on-site, you will need to create a comfortable space for them to use. You may also need to obtain equipment, such as a DVD player and screen, laptop computers, or tablets that patients can use to review aids that include audiovisual components.
7. Create a Library of Evidence-Based Educational Resources and Patient Decision Aids to Support Shared Decisionmaking
The cost of patient decision aids and other evidence-based resources should not be a barrier to implementing shared decisionmaking in your clinical practice. AHRQ's EHC Program offers a growing library of free, online, evidence-based shared decisionmaking resources, including consumer research summaries, clinician research summaries, and patient decision aids.
Other organizations also offer evidence-based educational resources and patient decision aids to support shared decisionmaking.
Refer to the Decision Support Resources section of this guide for more information.
It is challenging to translate the probabilistic nature of the evidence about treatments when discussing the risks and benefits of treatment options with patients.
Decision aids with pictures and scripts are very helpful to successfully translate evidence in an understandable way for patients according to France Légaré, M.D., Professor, Department of Family and Emergency Medicine, University Laval, Quebec, Canada (Interview: Jul 16, 2013).
8. Streamline Work Processes
Once you've decided on an approach and gotten some shared decisionmaking implementation experience under your belt, consider ways to streamline the shared decisionmaking work process. Streamlining the process so it is not a burden to anyone is a key to successful implementation. Two examples of how this can be done are described below.
|Streamlining Work Processes– Examples|
|Massachusetts General Hospital, a shared decisionmaking demonstration site of the Informed Medical Decisions Foundation (IMDF), designed its shared decisionmaking process so that primary care providers can prescribe a decision aid through a patient's medical record. To do this, Massachusetts General implemented a standardized four-step process.
|At the University of North Carolina (UNC), also an IMDF demonstration site, patients who are eligible for a decision aid are identified through a sophisticated clinical information system that uses clinical, lab, and billing data, as well as patient responses to an online questionnaire. These patients are then provided information in one of the following ways:
Streamlining the work process in ways like these allows you to easily integrate shared decisionmaking into the day-to-day operations of your practice.
9. Evaluate Shared Decisionmaking Implementation
Evaluating implementation allows you to fine-tune the practice of shared decisionmaking in your unique practice setting. A number of instruments are available to measure components of shared decisionmaking processes, including patient experiences and clinician actions toward shared decisionmaking.
Refer to the Evaluation Resources section at the end of this guide for more information.
Make Sharing Stories Part of the Process
Over time, enthusiasm for shared decisionmaking may wane. To counter this, regularly share success stories of your implementation efforts.
These stories, which can be shared verbally in meetings and through e-mail and other written communications, serve as memorable reminders of the value of implementing shared decisionmaking.
Decision Support Resources
AHRQ's EHC Program (https://effectivehealthcare.ahrq.gov) was launched in 2005 to increase the value of the health care Americans receive and, ultimately, to improve health outcomes. The EHC Program develops a variety of decision-support resources that compare the available evidence on the effectiveness, benefits, and harms of different treatments and interventions for specific health care conditions. These tools are regarded as important resources to be used in shared decisionmaking.
- Consumer Research Summaries
Over 50 plain-language information products are available that summarize evidence-based, patient-centered research findings on treatments for chronic conditions ranging from Type 2 diabetes to hypertension to depression. Each publication provides background on a specific clinical condition while comparing the benefits, risks, and side effects of treatment options. These materials, available in print and online formats, are central to AHRQ's ongoing Treatment Options awareness campaign, which encourages consumers to explore their treatment options, compare the benefits and risks of each, and prepare to discuss them with their health care providers. (https://effectivehealthcare.ahrq.gov/consumers)
- Patient Decision Aids
These online, interactive tools are designed to help patients with certain clinical conditions think about what is important to them when talking with their clinician about treatment options. They include information on the condition and the treatment options. (https://effectivehealthcare.ahrq.gov/products?f%5B0%5D=field_product_type%3Adecision_aid)
- Clinician Research Summaries
Serving as a complement to the consumer research summaries, these publications provide physicians, nurses, and other clinicians with the "clinical bottom line" on treatments, while grading the strength of evidence behind each research finding. More than 60 products are available. (https://effectivehealthcare.ahrq.gov/search?f%5B0%5D=field_product_type%3Aclinician_summary)
|Examples of How AHRQ's EHC Program Resources Are Being Used|
|Nurse educators from Brookhaven Memorial Hospital Medical Center, part of the Long Island Health Network, have incorporated AHRQ's EHC Program materials into patient teaching.13|
|StayWell Health Management, a population health management services provider, has incorporated AHRQ's EHC Program treatment summaries (in English and Spanish) for consumers into its pool of approved resources and has trained health coaches on their use.14|
|Urban Health Plan (UHP), a network of New York City health centers that serves more than 54,000 mostly Spanish-speaking and low-income patients in the Bronx and Queens, has ordered nearly 2,500 EHC Program summaries to support their English- and Spanish-language patient education efforts.15|
|The Illinois Primary Health Care Association (IPHCA) has partnered with AHRQ's EHC Program to provide evidence-based resources to support shared decisionmaking between patients and clinicians at the more than 450 community health center sites they represent. "We are using the Effective Health Care Program materials to educate clinical leaders at member health centers. In turn, they will ensure that evidence-based information is used for clinical decisionmaking," said Rajesh Parikh, M.D., the vice president of clinical services and workforce development.16|
|As part of an ongoing partnership, the American College of Cardiology (ACC) and AHRQ's EHC Program work together to help clinicians engage their patients in health care decisionmaking to improve care experiences and achieve the best possible outcomes. The ACC co-branded the EHC Program's consumer publication, "Measuring Your Blood Pressure at Home: A Review of the Research for Adults." Using plain language, the booklet describes the basics of blood pressure and the risks of hypertension, while outlining information about home blood pressure monitors. A list of questions that patients can ask their health care team is also included. The ACC distributed 500 copies of the free patient resource at its 2012 annual ACC Scientific Session & Expo in Chicago.17|
The U.S. Preventive Services Task Force (USPSTF) rigorously evaluates clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations, and preventive medications. It provides consumer fact sheets for many of the evidence-based recommendations it provides to clinicians (http://www.uspreventiveservicestaskforce.org/Tools/ConsumerInfo/Index/information-for-consumers).
Decision Aid Library Inventory (DALI) is a searchable database of publicly-available, evidence-based patient decision aids. This resource is made available by the Ottawa Hospital Research Institute.
Cochrane Musculoskeletal Group (http://musculoskeletal.cochrane.org/decision-aids) is a division of Cochrane that has developed a number of patient decision aids for specific topics related to osteoarthritis, osteoporosis, and rheumatoid arthritis. These products are specifically designed to provide evidence-based information about a treatment option, including benefits, harms, probabilities, and scientific uncertainties; help people clarify the value they place on the benefits, harms, and scientific uncertainties by describing the options; and ask people which benefits and harms matter most to them.
Informed Medical Decisions Foundation (IMDF) (http://www.informedmedicaldecisions.org/) works to advance shared decisionmaking through research, policy, clinical models, and patient decision aids.
The Mayo Clinic Shared Decisionmaking National Resource Center (http://shareddecisions.mayoclinic.org/), created by The Wiser Choices Program at the Knowledge and Evaluation Research (KER) Unit at Mayo Clinic, has prioritized helping clinicians share information about the treatment options and their consequences through the use of decision aids during the clinical encounter.
The goal of this program is to identify and evaluate ways to help patients make well-informed decisions, which reflect their values and goals, with their clinician. Decision aids—tools that share information about the options and their relative merits and downsides—have been designed in a user-centered way and developed by the Wiser Choices Program. These decision aids have been tested in randomized trials in usual clinical settings.
Some of Mayo Clinic decision aids are based on AHRQ EHC Program comparative effectiveness reviews.
The Decision Laboratory (http://www.decisionlaboratory.com/) at Cardiff University, Wales, United Kingdom, has created and researched several decision aids including BresDex, ProsDex, and AmnioDex. In addition, the laboratory's Decision Grid is a general decisionmaking tool for use by providers and patients during a clinical encounter.
Additional Resources for Implementing Shared Decisionmaking
AHRQ's Health Care Innovations Exchange (http://www.innovations.ahrq.gov) is designed to help clinicians solve problems, improve health care quality, and reduce disparities by providing specific types of information:
- Evidence-based innovations and quality tools.
- New innovations and tools published biweekly.
- Information from experts through events and articles.
The exchange also offers innovation profiles related to the implementation of shared decisionmaking (http://www.innovations.ahrq.gov/issue.aspx?id=85) and the use of decision aids to support shared decisionmaking (http://www.innovations.ahrq.gov/issue.aspx?id=161).
AHRQ Guidelines and Measures (https://www.ahrq.gov/gam/index.html) provides users a place to find information about its legacy guidelines and measures clearinghouses, National Guideline ClearinghouseTM (NGC) and National Quality Measures ClearinghouseTM (NQMC). This information was previously available on guideline.gov and qualitymeasures.ahrq.gov, respectively.
Resources for Evaluating Patient Education Materials
It's important to know that not all decision aids are created equal. As shared decisionmaking and patient-centered care become more widespread, a variety of developers are entering the decision aid market. Here are some tools to help you evaluate the quality and usability of patient decision aids and other evidence-based resources.
- The IPDAS Collaboration (http://ipdas.ohri.ca/) is a group of researchers, practitioners, and stakeholders from around the world. It has established a set of internationally approved criteria for determining the quality of patient decision aids using an evidence-informed framework.
- The Patient Education Materials Assessment Tool (PEMAT) (http://www.ahrq.gov/ncepcr/tools/self-mgmt/pemat.html), developed by AHRQ, provides a systematic method to evaluate and compare the understandability and actionability of patient education materials. This assessment tool helps you select, from the many patient education materials available, materials that are easier to understand and act on. Materials that score better on the assessment tool can be distributed to patients and consumers in hard copy, placed in an electronic health record system for providers to access at the point of care, or posted on patient Web portals.
Resources for Evaluating the Implementation of Shared Decisionmaking in Clinical Practice
Measures of Patient Experience
A key component of the reporting requirements under the Affordable Care Act (ACA) is public reporting on physician performance that includes patient experience measures. The collection and reporting of data from the CAHPS Physician Quality Reporting survey will fulfill this requirement.
A number of organizations, either by requirement or by choice, are beginning to publicly report on these measures. By giving consumers access to the CAHPS survey results, survey sponsors aim to make consumers more informed about their local physicians, better equipped to choose physicians and/or groups that meet their needs, and more engaged in decisions about their own care.
AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers and focus on aspects of quality that consumers are best qualified to assess, such as the communication skills of providers and ease of access to health care services. All CAHPS surveys include a core set of items that must be included in the survey.
- AHRQ's CAHPS Clinician & Group Survey (http://www.ahrq.gov/cahps/surveys-guidance/cg/index.html) asks patients about their recent experiences with clinicians and their staff. The CAHPS Patient Centered Medical Home (PCMH) Item Set (http://www.ahrq.gov/cahps/surveys-guidance/item-sets/PCMH/index.html) specifically includes many questions related to shared decisionmaking. Although this survey could be used by any physician practice, it is expected to be especially useful for physician practices that have adopted features of a PCMH.
AHRQ CAHPS surveys are administered to patients who answer questions about their experiences with their health care. These surveys are available in English and Spanish.
Other Instruments for Evaluating Shared Decisionmaking
The OPTIONS instrument (http://www.optioninstrument.com) is a validated, 12-item scale that can be used by trained observers to assess the extent to which clinicians involve patients in decisionmaking. This instrument may be useful in practices that are implementing the ongoing training and/or pilot testing of new shared decisionmaking processes in their practice settings.
The Ottawa Hospital Research Institute (http://decisionaid.ohri.ca/quality.html) provides a number of tools that can be used to monitor the use of decision aids, quality of decision support, and patient outcomes from shared decisionmaking.
Dartmouth-Hitchcock Medical Center provides tools that support the ongoing monitoring of patient decision quality. http://med.dartmouth-hitchcock.org/csdm_toolkits/step_7_quality.html
The process of evaluation keeps shared decisionmaking "alive" in the clinic and reinforces shared decisionmaking as part of routine practice.
This tool is to be used in conjunction with the Agency for Healthcare Research and Quality's SHARE Approach workshop. To learn more about the workshop, visit www.ahrq.gov/shareddecisionmaking.
3. Couët N., Desroches S., Robitaille H., et al. Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument. Health Expect 2013 Mar 4. PMID: 23451939.
4. Elwyn G., Scholl I., Tietbohl C., et al. "Many miles to go …": a systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Med Inform Decis Mak 2013;13 Suppl 2:S14. PMID: 24625083.
5. AHRQ Health Care Innovations Exchange. Innovation Profile: Shared Decisionmaking Tools Plus Peer Support Lead to More Efficient and Effective Mental Health Consultations and High Satisfaction (Pat Deegan, PhD & Associates). In: AHRQ Health Care Innovations Exchange [Web site]. Rockville (MD): [cited 2014 Feb 28]. Available: http://www.innovations.ahrq.gov/content.aspx?id=2870.
6. AHRQ Health Care Innovations Exchange. Innovation Profile: Telephone-Based Coaching on Shared Decisionmaking, Behavioral Change, and Health System Navigation Reduces Utilization and Cost (Group Health). In: AHRQ Health Care Innovations Exchange [Web site]. Rockville (MD): [cited 2014 Feb 28]. Available: http://www.innovations.ahrq.gov/content.aspx?id=3015.
7. AHRQ Health Care Innovations Exchange. Innovation Profile: Health Plan Leadership Promotes Shared Decisionmaking Through Use of Decision Aids by Surgeons, Contributing To Lower Joint Replacement Rates and Overall Health Care Costs (Health Dialog Services Corporation). In: AHRQ Health Care Innovations Exchange [Web site]. Rockville (MD): [cited 2014 Feb 28]. Available: http://www.innovations.ahrq.gov/content.aspx?id=2811.
8. AHRQ Health Care Innovations Exchange. Innovation Profile: Culturally Appropriate, Interactive Decision Aid Yields High Quit Rates Among Underserved, Low-Literacy Latino and Hispanic Smokers (University of Kansas Medical Center, Kansas City, KS). In: AHRQ Health Care Innovations Exchange [Web site]. Rockville (MD): [cited 2014 Feb 28]. Available: http://www.innovations.ahrq.gov/content.aspx?id=3254.
AHRQ Health Care Innovations Exchange. Innovation Profile: Health Plan Leadership Promotes Shared Decisionmaking Through Use of Decision Aids by Surgeons, Contributing To Lower Joint Replacement Rates and Overall Health Care Costs (Group Health). In: AHRQ Health Care Innovations Exchange [Web site]. Rockville (MD): [cited 2014 Feb 28]. Available: http://www.innovations.ahrq.gov/content.aspx?id=3836.
12. Loh A., Simon D., Wills C.E., et al. The effects of a shared decisionmaking intervention in primary care of depression: a cluster-randomized controlled trial. Patient Educ Couns 2007 Aug;67(3):324-32. PMID: 17509808.
13. www.ahrq.gov/professionals/clinicians-providers/partnership/action/index.html#lihn. Accessed February 16, 2014.
14. www.ahrq.gov/news/newsroom/case-studies/ktcoe88.html. Accessed February 16, 2014.
15. www.ahrq.gov/professionals/clinicians-providers/partnership/action/index.html#uhp. Accessed February 16, 2014.
16. www.ahrq.gov/professionals/clinicians-providers/partnership/action/index.html#iphca. Accessed February 16, 2014.
17. www.ahrq.gov/professionals/clinicians-providers/partnership/action/index.html#acc. Accessed February 16, 2014.